JOURNAL OF PALLIATIVE MEDICINE

Volume XX, Number XX, 2018 Original Article

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2017.0512

Common Items on a Bucket List

Vyjeyanthi S. Periyakoil, MD,1,2 Eric Neri, MS,1 and Helena Kraemer, PhD1

Abstract
Background: To provide preference-sensitive care, we propose that clinicians might routinely inquire about
their patients’ bucket-lists and discuss the impact (if any) of their medical treatments on their life goals.
Methods: This cross-sectional, mixed methods online study explores the concept of the bucket list and seeks to
identify common bucket list themes. Data were collected in 2015–2016 through an online survey, which was
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completed by a total of 3056 participants across the United States. Forty participants who had a bucket list were
identified randomly and used as the development cohort: their responses were analyzed qualitatively using
grounded theory methods to identify the six key bucket list themes. The responses of the remaining 3016
participants were used for the validation study. The codes identified from the development cohort were vali-
dated by analyses of responses from 50 randomly drawn subjects from the validation cohort. All the 3016
validation cohort transcripts were coded for presence or absence of each of the six bucket list themes.
Results: Around 91.2% participants had a bucket list. Age and spirituality influence the patient’s bucket-list.
Participants who reported that faith/religion/spirituality was important to them were most likely (95%) to have a
bucket list compared with those who reported it to be unimportant (68.2%), v2 = 37.67. Six primary themes
identified were the desire to travel (78.5%), desire to accomplish a personal goal (78.3%), desire to achieve
specific life milestones (51%), desire to spend quality time with friends and family (16.7%), desire to achieve
financial stability (24.3%), and desire to do a daring activity (15%).
Conclusions: The bucket list is a simple framework that can be used to engage patients about their healthcare
decision making. Knowing a patient’s bucket list can aid clinicians in relating each treatment option to its
potential impact (if any) on the patient’s life and life goals to promote informed decision making.

Keywords: advance care planning; bucket list; cross cultural; goals of care; multi ethnic; personalized medicine

Introduction Recent research has endorsed the importance of conduct-

‘‘
K icked the bucket,’’ an idiom denoting death, has
spawned the term, ‘‘bucket list.’’ The bucket list is
defined1 as ‘‘a list of things that one has not done before
but wants to do before dying’’ or more broadly2 ‘‘a number of
experiences or achievements that a person hopes to have or
accomplish during their lifetime.’’ For some, the items on their
bucket list may be a wish list of fantasies, such as winning the
lottery. For others, the bucket list can serve several concrete
purposes. It is a tangible recognition of our mortality and the
transience of our lifespans. It allows us to reflect on our per-
sonal values and identify important life milestones and expe-
riences that we want to have before we die. Finally, it is a sign
of hope and future orientation. Melges3,4 has shown that pro-
moting a future orientation can be effective in helping patients
identify personal goals.
ing goals-of-care conversations5–10 in patients with chronic
and serious illnesses as a vital part of the advance care planning
process. However, patients may not have the requisite medical
knowledge to understand the potential impact that their treat-
ment choices may have on their life and life goals. Clinicians,
on the other hand, are trained to focus on disease management
within a purely medical context and do not often ask about the
patient’s short-term and long-term life goals, let alone elaborate
on the impact of the treatment(s) on such goals. This commu-
nication gap can result in patients unknowingly embarking
upon treatment pathways that undermine or subvert their life
goals. If a patient wants to attend a beloved grandchild’s
wedding or travel to a favored destination, treatments that could
potentially prevent her from doing so should not be instituted
without ensuring her understanding of the life impact of such
treatments. One of the authors (V.S.P.) had a patient with

1
Division of Primary Care and Population Health, Center of Population Health Sciences, Stanford University School of Medicine,
Stanford, California.
2
VA Palo Alto Health Care System, Palo Alto, California.
Accepted December 20, 2017.

1
 2 PERIYAKOIL ET AL.
advanced cholangiocarcinoma whose cherished life goal was
to take his family to Hawaii before he died. After an informed
discussion of his options and the side effects of the proposed
cancer treatments, he decided to postpone the treatment in fa-
vor of taking his family to the favored destination.
To best provide preference-sensitive care, we propose that
clinicians should routinely inquire about their patients’ bucket
lists and discuss the impact of their lifestyles and the treatments
they choose on their short-term and long-term life goals. If used
appropriately, knowledge of the patient’s bucket list can serve as
a roadmap to guide clinicians in providing personalized care and
helping them make treatment decisions that enhance their life
goals. This approach may also foster a better therapeutic bond
by helping clinicians see the human aspects of their patients (the
person behind the disease); it will demonstrate tangibly to pa-
tients that their doctors care about their life goals and potentially
make the patients more adherent to the treatment plan.
This mixed-methods study was undertaken to determine
whether our study participants recognized the concept of a
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bucket list, and whether they were able to list specific items
on their bucket list. The data were analyzed to examine for
common bucket list themes.
Materials and Methods
Survey design
In April 2015, we deployed a survey to better understand
diverse Americans’ attitudes toward end-of-life issues. It was
developed by one of the authors (V.S.P.) based on prior
studies.11,12 The survey was beta-tested with a small group of
patients and families and their suggestions were used to refine
and finalize the questions. The project was reviewed and
approved by the Institutional Review Board at Stanford Uni-
versity School of Medicine.
Data collection
The survey was housed online on a secure Stanford server and
a link to it was posted on a dedicated online portal. Information
about the project was disseminated through the Stanford web
portals13–15 and through articles in mainstream media15–21
publicizing the project. The survey was administered once and
no personal health identifiers were collected in an effort to
promote participant confidentiality and honest responses
without concerns about individual scrutiny. The secure online
system was programmed to prevent ballot box stuffing. All
questions in the survey were set at ‘‘force response’’; partic-
ipants who did not respond to all the questions would be un-
able to submit the survey. Sociodemographic characteristics
including, age, gender, ethnicity/race, and self reported im-
portance ascribed to faith/religion/spirituality spiritual affili-
ation are shown in Table 1. The participants’ state of residence
was determined using their zip codes. The data presented here
were collected from July 2015 through December 2016. The
investigators had no direct contact with the participants.
Question prompt used for data collection
‘‘The term ‘‘bucket list’’ refers to a list of things that one
has not done before but wants to do before dying. Do you
have a bucket list? If yes, please list the items on your bucket
list if any in the order of importance.’’ Participants could
enter upto five bucket list items in text boxes provided.
Data analysis
Qualitative data analyses. A total of 3056 participants
completed the survey. To identify the base set of codes, 40
participants who listed bucket list items were identified ran-
domly and designated as the ‘‘development cohort’’ and the
remaining 3016 as the ‘‘validation cohort.’’ The development
cohort responses about their bucket list items were coded and
analyzed using grounded theory techniques22,23 as follows: first,
using an open coding approach, one of the authors (V.S.P.) and a
trained research assistant independently coded the transcripts
of the development cohort. During open coding, recurrent
themes and sub-themes were identified and characterized.
During axial coding, the categories were further refined, and
the relationships between them were characterized. Next, the
coders compared their assignment of codes and one of the
authors (H.C.K.) mediated any discrepancies between codes
assigned until agreement was reached. Efforts to maintain the
validity of the qualitative data included the following: to
evaluate inter-coder reliability, the exact assignment of codes
was assessed for 100% of the development cohort transcripts;
agreement was found to be greater than 90%, which was deemed
to be comparable with previous work. After 35 transcripts had
been coded, no new codes emerged from the next five transcripts
data indicating that saturation had been reached. At the end
of this process, the primary themes were identified, and the
development cohort was discarded and not used in subsequent
analyses. Actual words and phrases that participants used were
used to name the themes as feasible (Table 2 for exemplars).
The responses of the validation cohort were first reviewed
for the presence or absence of bucket list items. The bucket
list codes identified from the development cohort were vali-
dated by analyses of responses from 50 randomly drawn
subjects from the validation cohort. For those participants in
the validation cohort who submitted a bucket list, their re-
sponses were coded independently by the two coders for the
presence or absence of the individual primary themes iden-
tified by qualitative analyses of the development cohort.
Coders compared codes for inter-rater reliability. All dis-
crepancies in codes were reviewed by both coders with one of
the authors (H.C.K.) and discussed until consensus was
reached. The data were imported into SAS SAS 9.4, SAS
Institute (Cary, NC) for quantitative analyses.
Quantitative analyses
Participants with a bucket list were compared to those who
did not have one using a chi-square test for categorical variables
(e.g., race and gender) and the Mann-Whitney-Wilcoxon test for
continuous variables (e.g., age) and ordinal variables (e.g., level
of education and relative importance ascribed to faith/religion/
spirituality). For participants who had a bucket list, recursive
partitioning using Quality Receiver Operating Curve (QROC)
analysis24,25 helped explore differences between groups of
participants and identify subgroups with common patterns.
Results
Based on their self-reported place of residence, we had par-
ticipants from all the fifty states in the United States. Of the 3016
validation cohort participants, a vast majority (91.2% i.e., 2752
out of 3016) reported having a bucket list. In comparing the
group with a bucket list with those who did not have one,
analyses identified that age (Mann-Whitney-Wilcoxen v2 of
 COMMON ITEMS ON A BUCKET LIST 3

Table 1. Participants Demographics Comparing the Group with a Bucket List with Those without One
Does not have Comparison of those
a bucket list Has a bucket list without and with a bucket list
Mean Mean MWW MWW
Description N (SD) N (SD) Chi-Square p-value
Age in years 264 56.5 (14.3) 2752 50.0 (16.0) 39.01 <0.0001

Gender N Percentage N Percentage Chi-Square p value

Female 98 37.1% 1580 57.4% 40.19 <0.0001

Male 166 62.9% 1172 42.6%

Race/Ethnicity Chi-Square p value

Asian 71 26.9% 707 25.7% 8.83 0.07

Black or African American 19 7.2% 259 9.4%
Hispanic/Latino 46 17.4% 651 23.7%
Native Hawaiian/Pacific Islander 9 3.4% 96 3.5%
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Non-Hispanic White 119 45.1% 1039 37.8%

Marital Status Chi-Square p value

Single 67 25.4% 811 29.5% 13.8 0.003

Married 139 52.7% 1480 53.8%
Divorced 34 12.9% 345 12.5%
Widowed 24 9.1% 116 4.2%

MWW MWW
English is the language spoken at home Chi-Square p-value

No 35 13.3% 341 12.4% 0.50 0.48

Yes 229 86.7% 2411 87.6%
MWW stand for Mann-Whitney-Wilcoxon test.

39.01, p < 0.0001), and gender (v2 of 40.19, p < 0.0001) and
marital status (v2 of 13.8, p = 0.0032) were influential factors.
Participants who reported that faith/religion/spirituality was
important to them were most likely (95%) to have a bucket
list compared with those who reported it to be unimportant
(68.2%), v2 = 37.67 (Fig. 1). Women younger than 70 years of
age, for whom faith/religion/spirituality was at least somewhat
important, were most likely to have a bucket list at 94.9%.
Participants ‡61 years of age, who were not married and for
whom faith/religion/spirituality was not important were least
likely (31.8%) to have a bucket list.
Six primary themes were identified by analyzes of the
respondents’ bucket list:
(1) Desire to travel, within the nation or internationally, was
the most prevalent item on the bucket list (78.5%).
People most likely to list travel were college-educated
women (84.3%), followed by men <65 years of age for
whom faith was unimportant (80.6%). Unmarried men
‡65 years were least likely to list travel (52.3%) on
their bucket list.
(2) Desire to accomplish a personal goal 78.3% of the
participants identified this desire on their bucket list,
and there were no discriminating subgroups.
(3) Desire to achieve specific life milestones was the
third prevalent (51%) theme. This category was most
prevalent in women <33 years of age (69.3%) and
least in unmarried persons ‡59 years of age (22.3%).
(4) Desire to spend quality time with friends and family was
the fourth prevalent (16.7%) theme. Participants who
were ‡63 years of age were most likely to list this desire.
(5) Desire to achieve financial stability was the fifth prevalent
theme with an overall prevalence of 16.1% across all
ethnic groups and significantly higher in African Ameri-
cans (24.3%).
(6) Desire to do a daring activity was the last theme with a
prevalence of 15%. Younger participants (<26 years of
age) were exponentially more likely (28.9%) to report this
desire on their bucket list compared to older participants
(‡61 years of age) at only 7.6%.
Discussion
To the best of our knowledge, our study is the first to sys-
tematically investigate the concept of the bucket-list, an idea of
growing interest to the general public. This concept, if harnessed
thoughtfully, has great potential in engaging patients about their
health behaviors and health-related decision making by using a
framework that they can understand easily. Through our study we
have shown that adults and older adults from diverse backgrounds
are able to articulate their bucket list. Our study shows that those
who ascribe more importance to spirituality are more likely to
 Table 2. Common Bucket List Themes and Verbatim Exemplars
Bucket list themes
Desire to travel
Desire to accomplish a personal goal
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Exemplars
‘‘Go to Japan’’
‘‘Backpack through Europe’’
‘‘Go to Hawaii’’
‘‘Visit Australia’’
‘‘Visit Cuba’’
‘‘Cycle in italy and France’’
‘‘See Niagara Falls’’
‘‘Visit presidential libraries’’
‘‘See Anne Frank House & Corrie ten Boom Museum’’
‘‘Go back to Hong Kong’’
‘‘Travel to see the pyramids’’
‘‘Go on another short-term mission trip to distribute Bibles’’
‘‘Drive across the country’’
‘‘See Auschwitz & Bergen-Belsen’’
‘‘Acquire my masters to become a Pathology Assistant’’
‘‘Fly on a private plane’’
‘‘Become a tycoon’’
‘‘Be a backup singer for the Indigo Girls’’
‘‘Get my license’’
‘‘Meet fathers side of the family’’
‘‘I like to be able to swim in spite of age but first I need to know how to swim’’

‘‘I want to drive a Porsche car’’

‘‘Finish writing my book’’
‘‘Pass my 1964 Sting Ray to my daughter’’
‘‘Visit my country of birth’’
‘‘Run a marathon’’
Desire to achieve specific life milestones ‘‘Marry my boyfriend’’
‘‘Take entire family on a trip overseas’’
‘‘Have a daughter’’
‘‘Grandkids graduate’’
‘‘Reach our 60th wedding anniversary’’
‘‘Get back together with my kids’’
‘‘See kids get married and have kids’’
‘‘Reconnect with some old friends’’
‘‘See my grandchild in Iowa’’
‘‘See my oldest son have children’’
‘‘Watch my neices grow up’’
‘‘Open a gallery’’
‘‘Stay with my husband through everything’’
‘‘Become a grandmother’’
‘‘Take in a foster child’’
Desire to spend quality time with ‘‘Spend time with family’’
friends and family ‘‘Spend more time with family not in my area’’
‘‘Spend time with kids’’
‘‘Spend time with grandchildren’’
‘‘Spend time with beloved pets’’
‘‘Spend time with old friends’’
‘‘Spend time with all of my children together at the same time’’
‘‘Bring my seven siblings together and spend time’’
Desire to achieve financial stability ‘‘Be financially stable’’
‘‘Have enough money where it is not stressful’’
‘‘Debt free by 45 years of age’’
‘‘Earn enough money so as not to have to worry in my golden years’’
Have ‘‘all debts paid off’’
‘‘Be debt free’’
‘‘Pay off bills’’
‘‘Retire comfortably’’
‘‘Be Financially At Peace’’
‘‘Pay off all my debt’’
‘‘Give all my savings to my ex-wife and kids’’
‘‘Save enough money for kids college’’
‘‘Pay the mortgage off’’
Desire to do a daring activity ‘‘Run with the bulls’’
‘‘Swim with the sharks’’
‘‘Tackle a grizzly.’’
‘‘Go on a zipline’’
‘‘Fly a P51 Mustang’’
‘‘Surf 20 foot wave’’
‘‘Skydive and survive’’
‘‘Do bungee jumping’’
‘‘Dive off a bridge’’
‘‘Go deep sea fishing’’
‘‘Swim with humpback whales’’
‘‘Do hang gliding’’
‘‘Fish for sharks’’

4
 COMMON ITEMS ON A BUCKET LIST
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FIG. 1. Subgroups within patients who have a bucket list. Patients who reported faith, religion, or spirituality to be
important were more likely to have a bucket list compared to those who did not. For those who reported that faith was
unimportant, older (‡61 years) married people were more likely to have a bucket list (v2 = 8.83 and p = 0.07)
have a bucket-list. As having a bucket list is an expression of hope
and future orientation, this may be the underlying reason. We also
found that age influences the bucket list with younger patients
expressing the desire to complete more daring and risky activities
compared to older adults.
Experts have long recognized the importance of conduct-
ing goals-of-care26–32 discussions with patients. However,
current concepts of goals of care remain largely provider-
centered that is, driven by clinicians’ (and the healthcare
system’s) needs to have clarity in their patient’s treatment
preferences. In a narrow sense, goals of care discussions are
limited to elicitation of resuscitation preferences. Described
more broadly, goals of care discussions constitute a series of
conversations about healthcare decisions, specific treatments,
the intensity level of care desired and advance care planning.
Conceived this way, goals of care discussions focus exclu-
sively on end-of-life treatments choices and fail to capture
what matters most to patients, their desired milestones and
accomplishments in their lifetime, and how they wish to live.
This clinical tendency to approach healthcare-related deci-
sions in isolation without connecting them with the patients’
life goals is likely a key reason why patients may not see the
relevance of advance care planning or remain reluctant33–36
to complete the related documentation. Many patients, who
do not have the health literacy to truly comprehend the im-
pact of their medical decisions on their lives and their family
may prematurely choose certain treatment options only to
change their mind later when they start feeling the real impact
of these choices on their life. We propose the use of the
bucket list to help patients identify what matters most to
them. In contrast to concepts like advance care planning and
advance directives, which are not common knowledge to the
general public, the concept of the bucket list is well known to
many. For example, a Google search on 11/29/2017 yielded
almost 84 million results in 0.86 seconds for the term ‘‘bucket
list’’ compared to 4.5 million results for the term ‘‘advance
directives’’ in 0.81 seconds and only 533,000 results for the
term ‘‘advance care planning’’ in 0.57 seconds.
5
The national attention to precision medicine has recently
been broadened into a focus on precision health37–41 and
personalized care. True personalized care requires that cli-
nicians have a clear understanding of what matters most to
patients and what they wish to accomplish in their lives both
short term and long term. Asking patients to list their bucket
list is a simple way to elicit their future plans and allows their
doctors to help them craft a care-plan that will most optimize
the chances of fruition of the desires listed. Knowing the
desires listed on their patients’ bucket list will enable clini-
cians to go from merely eliciting patient’s preferences about
specific treatments in a clinical vacuum to anticipating the
impact of such treatments (if any) on the patient’s desired life
goals and plans. As patients progress through their life
course, their bucket list items will likely change as will their
goals of care. Knowing what matters most to patients and
their bucket lists, clinicians will be able to relate each treat-
ment option to its potential impact on the patient’s life using a
personalized approach. This assistance could range from (a) diet
and exercise counseling for a healthy patient whose life goal is
to run a marathon, (b) discussing the strategic timing of an
elective knee replacement for an older adult who wishes to
dance at his granddaughter’s wedding, to (c) counseling a se-
riously ill patient about treatment benefits (potential life pro-
longation) and burdens (distressing side effects like nausea, hair
loss) who may then wish to postpone/forego such therapy,
choosing instead to fulfill a bucket list item by traveling to a
final family reunion while still able to do so.
There are limitations to this study. It is a cross-sectional
study of a convenience sample, which limits the generaliz-
ability of our findings. As a web-based study conducted in
English, it limits participation of people with limited English
proficiency, poor technical literacy, and those who do not
have access to a computer. Also, people’s bucket list can and
should change over time, as they get older and also based
on their health status. Tracing changes in the bucket list over
the course of time was beyond the scope of our study. Fur-
thermore, the utility of a bucket list in clinical practice should
 6 PERIYAKOIL ET AL.
be studied—for example, will a clinician’s knowledge of the
patient’s bucket list lead to any changes in the care plan and
result in more, earlier and richer conversations about the
patient’s values and life goals?
Conclusion
Our study shows that diverse patients recognize the con-
cept of a bucket list and are able to articulate a number of
experiences or achievements that they hope to accomplish
during their lifetime. Clinicians can elicit the patient’s bucket
list and use it as a starting point to initiate goals of care
discussions and as a strategy to craft personalized care plans
based on a patient’s own life goals.
Acknowledgments
Dr. Periyakoil’s work is funded by R25 MD006857,
NIMHD NIH, U54 MD010724/MD/NIMHD NIH, and
AG047366, NIA NIH, Department of Veterans Affairs and
Stanford University School of Medicine.
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Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Vyjeyanthi S. Periyakoil, MD
Division of Primary Care and Population Health,
Center for Population Health Services
Stanford University School of Medicine
1265 Welch Road
Stanford, CA 94305
E-mail: periyakoil@stanford.edu